with Rod Moser, PA, PhD

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The neurological gag response (gagging reflex) is a protective measure to help prevent us from choking on food or objects attempting to go down our throats — such as those wooden tongue depressors used in medical offices, or dozens of unpleasant things that your dentist does while working on your teeth. When the back of the tongue, soft palate, pharynx (back of the throat), or even the tonsils are touched, a powerful gag response can occur.

In my primary care practice, the most common cause of a gag response is the dreaded tongue depressor. I once had a man who begged me not to use one. He said that he would surely vomit if I did. When he said those frightening words, I had already lifted a tongue depressor out of the jar and was holding it. Just seeing the tongue depressor caused him to vomit all over the floor. He had proven his point.

Mentally, if we think we may gag, we usually do. I am not a big fan of having those cardboard or plastic x-ray things in my mouth for dental films. I am fine for the front films, but my eyes start to water just thinking about the films of those molars. It gags me every time. There is something about dental procedures that doubles or triples my salivation. As my drool starts to fill my mouth, this can cause me to gag as well. I often ask if I can hold the little suction device (spit sucker?) myself.

Watching someone vomit can trigger gagging, dry heaving, and vomiting in others. I witnessed this many times in elementary school when one kid would barf, followed by several other sympathetic barfs from the observers. This can turn into a real barforama. I don’t like watching kids eat boogers. A particularly stinky diaper is not that appealing either. You kind of get used to both, but they can make me gag. Some of you may be gagging just reading about these things.

Both sights and smells can make your gag. Watching a particularly gory movie with lots of blood and guts can do it. Watching Andrew Zimmern on Bizarre Foods eat live bugs, worms, spiders, or bat sushi has a high gag potential. I had to dispose of a dead skunk a few years ago. Skunks, of course, smell terrible when they are alive, but a dead one was even more challenging. There are a lot of stinking things in a medical office, but a sense of decency prevents me from listing them.

A particularly funny HBO episode of It’s Always Sunny in Philadelphia involved a woman who gagged every time she thought about a high school boyfriend. In telling the story, she would gag and friends, listening to the story, would also gag, just from watching her retching response.

Children (and adults) hate tongue depressors. Many even call them “gag sticks”. Given a chance, most children will open their mouths wide enough and long enough to conduct a proper exam without using a tongue depressor. I can get them to say the standard “Ahhhhh” or better yet, tell them to growl like a monster. Any of these vocalizations can open up the throat for an examination. Sometimes, they will be screaming and crying “Noooooo”, which really opens the mouth well enough to suffice. In most cases, it is not an option to skip the mouth and throat examination just because they refuse. If they have upper respiratory symptoms, we must examine this area. Period.

For those that will not open their mouths (and I have plenty of those), I can use the tongue depressor as a threat, and give them a choice: open up wide or I will need to use “the stick”. I can trick them: let’s stick out our tongues and see who has the longest one, or open up real wide so I can count your teeth. Obviously, I have no interest in the number of teeth, but this little trick does seem to work.

When I am seeing a patient with a sore throat, there is a very good chance, based on my examination that I will need a throat swab to rule out strep. My medical assistant feels she is saving me time by taking the specimen first, before I examine the child. If she gags them, and she most always does, the child is not going to be a happy camper when I ask to examine their throat. I have seen her do swabs; a brutal-looking technique not unlike plunging a clogged toilet. Made me gag just watching it.

I prefer to do my own throat swabs. That way I can examine the throat first, and then take the swab from certain areas of concern, not just blindly digging around. And, I do them gently after carefully explaining the procedure.

To prevent kids (and adults) from gagging, I tell them the following:

1. You need to open your mouth as wide as you can, and stick out your tongue. If I see hands likely to grab the swab, I will ask them to sit on their hands.

2. I tell them that it is very important NOT TO CLOSE THE EYES. When we close our eyes, we gag, so if you will just hold your eyes wide open and stare at me, you will not likely gag. If you start to gag, I will take out the swab immediately.

3. They are instructed to “pant like a puppy”, instead of saying Ahhhh.

4. I promise to be very fast. Just touch, touch, and I will take the swab out quickly.

5. Children earn a lollipop or stickers (or both) if a swab is done successfully.

At least once a month, none of these will work, and I end making someone vomit. If they close their eyes and gag, I can blame it on them for closing their eyes. There is a certain soon-to-vomit look that occurs a few seconds before the eruption, giving me time to reach for the barf pan under the sink. At least we have tile floors in the clinic now. When we first moved to this office, it was carpet, if you can believe it. Stained carpet, obviously, but it did match the stained chairs.

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Rod Moser, PA, PhD, is a primary care physician assistant with more than 35 years of clinical experience in adult and pediatric health and practices full-time clinically in Northern California. He is on the clinical faculty with the department of family practice at the University of California-Davis.

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